A survey of healthcare-seeking practices and related stigma among community- and street-based children in Cambodia

Abstract

Background

Globally, street children comprise a growing population of vulnerable children. Understanding how they interact with healthcare systems is fundamental to efforts to improve their health and well-being.

Methods

We surveyed 75 street- and community-based children in Battambang, Cambodia regarding their healthcare-seeking practices and related stigma.

Results

For demographically similar street and community children, hospitals and pharmacies were preferred healthcare institutions, with this choice being motivated by the caretaker’s decision or cost. Street children reported increased fear of being refused treatment.

Conclusions

Street children and demographically similar community children have similar healthcare-seeking practices and preferences, although street children face increased stigmatization.

Introduction

Globally, tens of millions of children work, sleep or otherwise depend on the streets to survive, and in the face of globalization and urbanization, this number is likely to increase.¹ Street children experience high risk for a range of health problems.^2,3 Further, the poverty and material disadvantages that frequently drive children to the street also present significant barriers to seeking healthcare.¹ Social services may be underresourced and unable to meet the needs of street children in low- and middle-income countries such as Cambodia.⁴ Understanding how street children currently interact with healthcare in such underresourced settings is essential to the development and implementation of future interventions and services aimed at improving their health. In addition, few studies have investigated how street children might differ from community-based children in their healthcare-seeking practices and related stigma.² In this study we examined if and how community- and street-based children in Battambang, Cambodia differed in these regards.

Materials and methods

We surveyed community- and street-based children (N=75) living in Battambang, Cambodia, from June to August 2015. Street children between 10 and 17 y of age were eligible for the study if they had spent the past 2 weeks or more living and/or working (e.g., begging or collecting recyclables) on the street. These children were sampled from either lists provided by government social workers who oversaw child-oriented services or from venues they were known to frequent (e.g., parks, markets or city dump). Community children of the same age range were also sampled from lists provided by government social workers; thus they were typically economically disadvantaged and lived in the same areas of the city as street children, but without their livelihood being tied to the street. Survey questions, administered in Khmer by Cambodian interviewers, probed participants’ healthcare-seeking preferences, practices and perceptions of care-related stigma.

We used Stata/SE (version 13; StataCorp, College Station, TX, USA) to produce descriptive statistics of street and community children; χ² and Fisher’s exact tests were used as appropriate to compare responses between groups. The study was approved by the Cambodian National Ethics Committee for Health Research and Duke University’s Institutional Review Board for Research with Human Subjects.

Results and discussion

A total of 75 children (41 community-based and 34 street-based) participated in the study. Community and street children were similar in demographic characteristics (see Supplementary Table 1). Overall the sample included more boys (61.3%) than girls and the average age was 13.9 y (SD 2.0). A majority of children (82.7%) had attended primary school but did not complete it; similarly, a majority (69.3%) also reported having a government-issued ID Poor Card, an indicator of economic disadvantage. The healthcare practices and attitudes of street and community children are summarized in Table 1. The two most common options for receiving healthcare—hospitals (community 35.9%, street 32.3%) and pharmacies (community 28.2%, street 32.3%)—were similarly preferred across groups. There was little preference for health services provided by non-governmental organizations (community 2.6%, street 9.7%) and traditional healers (community and street 0%). Healthcare choices were most often determined by the children’s caretaker, defined as an older individual who helps them when in need (community 41.5%, street 35.3%), and cost (community 17.1%, street 20.6%). While children appeared similarly likely to seek care for health concerns in general, street children were less likely to seek healthcare for feeling emotionally distressed (see Supplementary Table 2; community 79.5%, street 48.4%; p=0.01). Overall, 89.3% of children responded affirmatively to at least one of the five questions probing stigma, and responses to specific items were generally similar across groups. There was a trend for street children to more frequently express fear of being refused treatment, although the group comparison was not significant at the p<0.05 level (community 33.3%, street 54.8%; p=0.07).

Table 1.

Healthcare-seeking practices and stigma among street and community children in Battambang, Cambodia

Survey Item	Community (n=41), n (%)	Street (n=34), n (%)	p-Value
Practices
Difficulty seeking treatment			0.62
Hard	14 (35.9)	14 (45.2)
Somewhat hard	17 (43.6)	13 (41.9)
Somewhat easy	8 (20.5)	4 (12.9)
Easy	0 (0.0)	0 (0.0)
Top choice for receiving care			0.08
Hospital	14 (35.9)	10 (32.3)
Pharmacy	11 (28.2)	10 (32.3)
Private clinic	7 (17.9)	2 (6.5)
Public clinic	3 (7.7)	0 (0.0)
Home visit	1 (2.6)	4 (12.9)
Non-governmental organization	1 (2.6)	3 (9.7)
Drop-in centre	0 (0.0)	2 (6.5)
Other	2 (5.1)	0 (0.0)
Reason for top choicea
My caretaker decided for me	17 (41.5)	12 (35.3)	0.59
The treatment is cheap	7 (17.1)	7 (20.6)	0.70
I am sure I will get assistance	8 (19.5)	3 (8.8)	0.19
It is close	2 (4.9)	0 (0.0)	0.19
I feel comfortable going there	3 (7.3)	1 (2.9)	0.40
I heard good things about it	7 (17.1)	2 (5.9)	0.14
Other	4 (9.8)	6 (17.6)	0.32
Stigma
When seeking treatment from a healthcare centre, a doctor or a trained medical professional, did you ever…
feel it was hard to tell the provider about your problem or illness?	24 (61.5)	20 (64.5)	0.80
worry about what the provider would think?	20 (51.3)	16 (51.6)	0.99
worry that getting help would make things worse?	33 (84.6)	23 (74.2)	0.28
think the provider would not be helpful?	19 (48.7)	14 (45.2)	0.62
think the provider would refuse you help?	13 (33.3)	17 (54.8)	0.07

^aParticipants were able to select more than one reason and sometimes did not endorse any reasons, thus percentages do not sum to 100%.

Our findings suggest that economically disadvantaged community and street children generally demonstrate similar preferences and motivations when seeking healthcare. The similarities between the two groups may be attributable in part to their shared economic disadvantage, particularly given the high level of average out-of-pocket health expenditures in Cambodia.⁵ Cost was a frequently-reported determinant of healthcare preference and the hospital—which provides free services for people with an ID Poor Card—was the most common preference. Further, our findings are likely influenced by the transient nature of definitions of street vs community children.³ If children at the bottom of the economic ladder go back and forth between street-based and non-street activities, their categorization as a street child would partly be a function of timing. While not reaching conventional statistical significance in our small sample, the trend suggesting increased fear of service refusal among street children is consistent with literature describing those actively on the streets as a marginalized and stigmatized group.² This is one of only a few studies to use a community-based comparison group against street children’s healthcare practices; however, the limited scope of the study prevents significant generalization of the findings regarding healthcare-seeking practices and stigma of community- vs street-based populations of children. We recommend that future studies include community comparisons in order to better contextualize any unique experiences faced by children on the street.

Conclusion

Street children appear to demonstrate similar healthcare-seeking practices relative to demographically similar community children, perhaps due in part to their shared economic disadvantage. However, street children may face increased stigmatization when seeking healthcare.

Supplementary data

Supplementary data are available at International Health online (http://inthealth.oxfordjournals.org/).